EDUCATION AND TRAINING
Modelling district nurse expertise Michelle Burke
Tutor, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London
ABSTRACT
As changes in society and health provision mean that one in four people over the age of 75 will require nursing care at home, pre-registration adult nurse education increasingly prepares student nurses for a future career within the community. District nurses undertake complex, multidimensional health and social assessments and care in a non-clinical setting and work in partnership with patients and their significant others to promote practical and psychological coping mechanisms and self-care. The district nurse’s first assessment visit is key to developing a therapeutic partnership and it is often during this visit that expertise in district nursing practice emerges. The holistic, contextual and dynamic aspects of nursing in the home setting can make district nursing expertise difficult to illustrate and demonstrate within the classroom setting. This article explores the ways in which an understanding of expertise development theory can enable the tacit expertise that occurs within the first assessment visit to be made visible to student nurses, using simulation and expert narrative as a pedagogical strategy.
KEY WORDS
w District nursing w First assessment visit w Models of expertise w Pedagogy w Simulation
608
Nurse ‘intuition’ and influential literature Patricia Benner’s seminal work From Novice to Expert (1984) was developed using Dreyfus and Dreyfus’s research on models of skill acquisition published in the early 1980s. Dreyfus and Dreyfus (1986:19) later identified that ‘a person usually passes through at least five stages of qualitatively different perceptions of a task and/or mode of decision making as a skill improves’. Benner (1984) used the model as a framework for staging nursing proficiency: novice, advanced beginner, competent, proficient and expert. The model was subsequently adapted and incorporated into nursing curricula. The concept of nurses using ‘intuition’ within the expert stage produced controversy within the nursing literature. English (1993) argued that intuition, as described by the Dreyfus and Dreyfus (1986) model, refers principally to decision making, rather than the intuition suggested within Benner’s model. They pointed out that, commonly, the role of the expert is to act as a role model and that it would therefore be helpful if experts could ‘explain their acute perceptiveness’ (English, 1993:391). Benner and Tanner (1987) introduced a more tangible description of intuition into the model using Dreyfus and Dreyfus’s (1986) six key aspects of intuitive judgment: pattern recognition, similarity recognition, sense of salience, deliberate rationality, commonsense understanding and skilled know-how. Dreyfus and Dreyfus (1986) also drew an explicit distinction between ‘knowing that’ and ‘knowing how’, explaining ‘knowing that’ as rule guided and ‘knowing how’ as experience based. Gardner (2013) argues that theoretical knowledge or ‘knowing that’ can be broken down and explained to others, but that expert knowledge or ‘knowing how’ is intuitive, holistic, tacit and case specific and that it cannot be expressed in words or formally taught. Using simulation and expert narrative as pedagogical strategies in the classroom setting is one way of exposing and exploring the tacit expertise inherent within district nurse first assessment visits.
District nursing first assessment visits Kennedy (2004) explored the nature of knowledge required by district nurses to carry out first assessment visits and considered the relationship of this knowledge to the subsequent decisions the district nurses made. Kennedy (2004) presented a typology of district nursing knowledge that included six dimensions of ‘knowing’, with ‘each
© 2014 MA Healthcare Ltd
C
hanges in UK age demographics and alterations in the way that health care is delivered mean that one in four people over the age of 75 will now require nursing care at home (Queen’s Nursing Institute (QNI), 2011). As a result, pre-registration adult nurse education is increasingly preparing student nurses for a future career within the community (QNI, 2013). District nurses undertake complex, multidimensional health and social assessments and care in a non-clinical setting and work in partnership with patients and their significant others to promote practical and psychological coping mechanisms and self-care.The district nurse first assessment visit is key to developing a therapeutic partnership and it is often during this visit that expertise within district nursing practice emerges (Bryans and McIntosh, 2000). The holistic, contextual and dynamic aspects of nursing in the home setting can make district nursing expertise difficult to illustrate and demonstrate within the classroom setting. This article will explore how an understanding of expertise development theory can enable the tacit expertise that occurs within the district nurse first assessment visit to be made visible to student nurses, using simulation and expert narrative as a pedagogical strategy.
Email: [email protected]
British Journal of Community Nursing December 2014 Vol 19, No 12
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 16, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION AND TRAINING dimension combining ways of knowing into coherent wholes to facilitate understanding’ (Kennedy, 2004:404): w Getting to know the patient in their own setting w Getting to know the carer w Knowing what needs to be done now w Knowing what may happen in the future w Knowing/recognising knowledge deficits w Knowing the community resources and services. Kennedy (2004) differentiates between ‘knowing that’ as theoretical knowledge and ‘knowing how’ as practical knowledge and suggests that the theoretical knowledge of experienced nurses becomes embedded into the practice context. If ‘knowing how’ is practical knowledge, as Kennedy suggests, this can potentially be explored and modelled within the classroom setting using simulation and expert narrative.
Knowing the patient: embodied understanding ‘of’ and ‘in’ practice Dall’Alba and Sandberg (2006) introduce the concept of an embodied understanding ‘of ’ and ‘in’ practice or knowing, acting and being, which they argue is overlooked in stage models such as Benner and Tanner’s (1987). They propose an alternative model of skill development that incorporates horizontal and vertical dimensions that allow for a range of development trajectories. The horizontal dimension relates to skill that accompanies experience, and the vertical dimension relates to variations in the embodied understanding ‘of ’ and ‘in’ practice. Dall’ Alba and Sandberg (2006) explain that the way in which professional practice is understood, in an embodied sense, is fundamental to how the practice in question is performed and developed. Dall’ Alba and Sandberg (2006) explore the concept of ‘unfolding circularity’ and Dewey’s notion of ‘habit’ and ‘continuity of experience’ and use these to explain how an embodied understanding of practice forms the basis for the professional skill that is being developed.
© 2014 MA Healthcare Ltd
Relevance to community nursing Research by McMurray (1992) considered the difference in practice between novice and expert nurses in community nursing. Their data identified an expert as operating with the following characteristics synchronously: w Knowledge w Empathy w Appropriate communication w Holistic understanding w Ability to get right to the problem at hand w Self-confidence in perceptions, judgments and intervention strategies. These characteristics mirror the expert practice inherent within Benner and Tanner’s (1984) expert stage and Kennedy’s (2004) typology of knowledge. The patient assessment process is seen by Kennedy (2004) as an inherently social process, with nurses getting to know the patient and the carer in their own setting in order to understand how the patient is responding to their particular clinical situation. This is supported by Benner
and Tanner (1987:28), who argue that the
‘expert nurse needs an in-depth knowledge of the patient in order to operate with a well developed sense of salience’.
How to teach expertise: simulation and expert narrative Although context-free knowledge and skills have traditionally been acquired in formal professional education, consideration is now being given to instructional conditions that explore the prospective development of expertise (Bransford and Schwartz, 2009). Dall’Alba and Sandberg (2006: 38) mention Benner’s work, emphasising that
‘professional development is not only accumulating knowledge and skills, but learning to deal with situations encountered in qualitatively different and more complex ways’. Bransford and Schwartz (2009:441) suggest that it is
‘valuable to let students experience performance conditions or the complexities of a situation and then provide and demonstrate information about an expert performance, as this helps them to understand these techniques in relation to their own success and failures’. The description by Bransford and Schwartz (2009) reflects the simulated first assessment visit session that firstyear adult nursing students take part in. The session aimed to enable students to gain insight into the principles of holistic nursing care in the home setting prior to undertaking their community practice placements in the second year. The learning outcomes for the session included the students gaining an understanding of how the therapeutic nurse–patient relationship supports decision making and the optimisation of patient wellbeing and independence (Doherty and Thompson, 2014). Students were also supported to use critical thinking skills to apply the nursing process to prioritise and co-ordinate care planning and to recognise and proactively manage risk during a home visit.
Simulation A simulation room was created to replicate the ambience of a patient’s living room and a typically complex first assessment visit scenario was developed.The simulation was built around the environmental fidelity of the simulation room, rather than any interaction or role play with actors. The students were given a district nurse referral letter from a GP asking them to visit a patient to assess a wound on the patient’s leg, to measure blood pressure and to undertake urinalysis and some routine blood tests. Background information was also provided, including the patient’s past medical history (type 2 diabetes, osteoporosis), medication and the observation that the patient has recently been widowed and her neighbours are concerned about how she is coping. When the students enter the ‘living room’, the curtains are drawn and the radio is on. A mannequin is sitting on the settee, with a wound dressing on ‘her’ leg and a cat on ‘her’ lap. The mannequin is sitting on an incontinence pad and there is a commode next to the sofa. There is a tin of
British Journal of Community Nursing December 2014 Vol 19, No 12
609
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 16, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION AND TRAINING
‘skilled performance involves intuitive assessment of each situation against a background of previous experience … or skilful know-how.’ The use of concept maps help the students to visualise the connections between the actual and potential problems identified—for example, how pain can affect mobility, which could then cause incontinence and subsequent pressure ulcer development, leading to depression and isolation, which then affects wellbeing.
Student responses and tools for analysis Initially, the students, acting within the realms of Benner’s (1984) ‘novice’ stage, plan care under the protection of rules and assessment tools. Gatley (1992) proposes that the subsequent development of flexibility when moving naturally through the stages of proficiency can be arrested by an overreliance on assessment ‘tools’. It is arguably the case that there are often no generalisable rules in district nurse first assessment visits, since each situation is subtly unique and unfolds differently. In complex social and health-care scenarios in the home setting, assessment tools or checklists could be seen as a barrier to expert practice. A novice practitioner can falter in a complex situation by trying to fit many intangible problems into an assessment tool and can feel overwhelmed by the issues identified. Within this simulation scenario a number of assessment tools could have been used, such as wound assessment, pressure ulcer risk assessment, depression and nutrition screening tools. However, the ‘expert’ nurse often does not base decision making on these tools, rooted as they are in Benner’s (1984) novice/advanced beginner stages. Throughout the session, emphasis is placed on the therapeutic relationship between the nurse and the patient and the often sensitive negotiations involved in shared care planning. The ‘expert’ nurse sees the situation as a whole and uses his/her experience
610
‘of ’and ‘in’ practice and ‘intuition’ to ‘zero in on the accurate region of the problem’. As a result, the session naturally evolves into what Gatley (1992) acknowledges as a strength of Benner’s (1984) work—uncovering expertise in clinical practice.
Evaluations of simulation The first assessment visit simulation session was evaluated positively by the students. Students either ‘agreed’ or ‘strongly agreed’ that they had a better understanding of the community nurse role in the home setting and felt more confident about their forthcoming community placement. Further evaluation after the students’ community placements is also planned.
Towards intuitive expertise: implications for practice The described strategy for education towards expertise is supported by McMurray (1992), who identifies that educators should acknowledge the value of intuitive as well as analytical thinking created through simulated case studies and argues that education must be designed to stimulate perceptual as well as analytical abilities in the learner. McMurray (1992) suggests that this is achieved though educational practice that stimulates inferential and intuitive thinking in learners. Dall’Alba and Sandberg (2006) explain how education can promote the development of understanding ‘of ’ and ‘in’ practice, creating opportunities that call into question and extend students’ understanding of practice. This is supported by Bransford and Schwartz (2009), who differentiate between ‘learning expertise and teaching expertise’, with learning expertise involving proactive learners engaging in what Ericsson (1993) termed ‘deliberate practice’. Bransford and Schwartz (2009) argue that, within deliberate practice, students practise on problems that stretch them rather than doing what they can already do again. Gatley (1992) argues that active enquiry, which is fostered by inductive teaching, is required to move beyond Benner’s (1984) ‘competence’ stage. Community nursing education should aim to engage the learner in context-driven, classroom-based scenarios in order to model expert practice and enable intuitive, adaptive and flexible practitioners who are responsive to the complex and everchanging community practice environment to develop. Community nurses working with pre-registration students during their community placements could also aim to use the principles of the simulation session. This makes visible to students the expertise inherent within their role and supports students to reflect on and explore the complexities of the situations they experience in practice.
Conclusion This article has examined how theoretical models of expertise can be used to place district nursing expertise into the pedagogic structure of nurse education. The range and nature of district nursing knowledge involved in the first assessment visit and the cognitive and affective aspects inherent within district nursing practice have been
© 2014 MA Healthcare Ltd
biscuits, an ashtray with cigarette ends and a tin box full of analgesics and laxatives within the patient’s reach on a side table. A stack of unpaid bills and a walking stick are next to the sofa and a walking frame is placed in a corner of the room.The mannequin has slippers dangling off her feet and there is a stack of old newspapers piled around the sofa. A pillow and blanket are hidden behind the sofa. The students enter the simulation room in small groups and work together looking for clues in the room. It is suggested that they use these, along with the information they have in the referral letter, to identify actual and potential problems. They do not undertake the practical tasks requested by the GP in this session. After their immersion in the patient’s ‘living room’, the students come together as a group with the facilitator where actual and potential problems are elucidated and discussed. The students have the opportunity to visualise decision making and care planning through the lens of a subject expert—making visible the ‘knowing that’ and also the ‘knowing how’, using the facilitator’s experience as a district nurse. This attempts to demonstrate the concept of intuition as explored by Dall’Alba and Sandberg (2006), who identify that
British Journal of Community Nursing December 2014 Vol 19, No 12
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 16, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION AND TRAINING considered (Bryans and McIntosh, 2000). By using contextbound simulated or real district nurse scenarios along with expert narrative, the concept of expertise can be made visible to learners, both within the education setting and in practice. Furthermore, an understanding of the importance of knowing individual patients, using an embodied understanding ‘of ’ and ‘in’ practice (Dall’ Alba and Sandberg, 2006) and ‘knowing how’ (Dreyfus and Dreyfus, 1987) can be developed. BJCN Accepted for publication 14 November 2014
Ericsson KA, Krampe RT,Tesch-Römer C (1993) The role of deliberate practice in the acquisition of expert performance. Psych Rev 100(3): 363–406 Gardner L (2013) Benner, reflections and experiences: some further thoughts. Nurse Educ Today 33(3): 183–4 Gatley E (1992) From novice to expert: the use of intuitive knowledge as a basis for district nurse education. Nurse Educ Today 12(2): 81–7 Kennedy C (2004) A typology of knowledge for district nursing assessment practice. J Adv Nurs 45(4): 401–9 McMurray A (1992) Expertise in community health nursing. J Community Health Nurs 9(2): 65–75 Queen’s Nursing Institute (2011) Nursing People at Home:The Issues, the Stories, the Actions. http://tinyurl.com/ldg5lwe (accessed 14 November 2014) Queen’s Nursing Institute (2013) Transition to Community Nursing Practice. http://
Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA Benner P, Tanner C (1987) Clinical judgment: how expert nurses use intuition. Am J Nurs 87(1): 23–34 Bransford J, Schwartz D (2009) It takes expertise to make expertise: some thoughts about why and how and reflections on the themes. In: Ericsson AK (ed), Development of Professional Expertise: Toward Measurement of Expert Performance and Design of Optimal Learning Environments. Cambridge University Press, Cambridge: 432–48 Bryans A, McIntosh J (2000) The use of simulation and post-simulation interview to examine the knowledge involved in community nursing assessment practice. J Adv Nurs 31(5): 1244–51 Dall’Alba G, Sandberg J (2006) Unveiling professional development: a critical review of stage models. Rev Educ Res 76(3): 383–412 Doherty M, Thompson H (2014) Enhancing person-centred care through the development of a therapeutic relationship. Br J Community Nurs 19(10): 503–7 Dreyfus H, Dreyfus S (1986) Mind over Machine:The Power of Human Intuition and Expertise in the Era of a Computer. Free Press, New York NY English I (1993) Intuition as a function of the expert nurse: a critique of Benner’s novice to expert model. J Adv Nurs 18: 387–93
tinyurl.com/muauhpk (accessed 14 November 2014)
KEY POINTS
w It is useful to use simulation and expert narrative as pedagogical strategies to explore tacit expertise in the district nurse’s first assessment visit
w It is important for learners to practise on complex problems, rather than repeating what they already know
w There is significant value in intuitive as well as analytical thinking, i.e. knowing the patient and having an embodied understanding ‘of’ and ‘in’ practice
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Modelling district nurse expertise Michelle Burke
Tutor, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London
ABSTRACT
As changes in society and health provision mean that one in four people over the age of 75 will require nursing care at home, pre-registration adult nurse education increasingly prepares student nurses for a future career within the community. District nurses undertake complex, multidimensional health and social assessments and care in a non-clinical setting and work in partnership with patients and their significant others to promote practical and psychological coping mechanisms and self-care. The district nurse’s first assessment visit is key to developing a therapeutic partnership and it is often during this visit that expertise in district nursing practice emerges. The holistic, contextual and dynamic aspects of nursing in the home setting can make district nursing expertise difficult to illustrate and demonstrate within the classroom setting. This article explores the ways in which an understanding of expertise development theory can enable the tacit expertise that occurs within the first assessment visit to be made visible to student nurses, using simulation and expert narrative as a pedagogical strategy.
KEY WORDS
w District nursing w First assessment visit w Models of expertise w Pedagogy w Simulation
608
Nurse ‘intuition’ and influential literature Patricia Benner’s seminal work From Novice to Expert (1984) was developed using Dreyfus and Dreyfus’s research on models of skill acquisition published in the early 1980s. Dreyfus and Dreyfus (1986:19) later identified that ‘a person usually passes through at least five stages of qualitatively different perceptions of a task and/or mode of decision making as a skill improves’. Benner (1984) used the model as a framework for staging nursing proficiency: novice, advanced beginner, competent, proficient and expert. The model was subsequently adapted and incorporated into nursing curricula. The concept of nurses using ‘intuition’ within the expert stage produced controversy within the nursing literature. English (1993) argued that intuition, as described by the Dreyfus and Dreyfus (1986) model, refers principally to decision making, rather than the intuition suggested within Benner’s model. They pointed out that, commonly, the role of the expert is to act as a role model and that it would therefore be helpful if experts could ‘explain their acute perceptiveness’ (English, 1993:391). Benner and Tanner (1987) introduced a more tangible description of intuition into the model using Dreyfus and Dreyfus’s (1986) six key aspects of intuitive judgment: pattern recognition, similarity recognition, sense of salience, deliberate rationality, commonsense understanding and skilled know-how. Dreyfus and Dreyfus (1986) also drew an explicit distinction between ‘knowing that’ and ‘knowing how’, explaining ‘knowing that’ as rule guided and ‘knowing how’ as experience based. Gardner (2013) argues that theoretical knowledge or ‘knowing that’ can be broken down and explained to others, but that expert knowledge or ‘knowing how’ is intuitive, holistic, tacit and case specific and that it cannot be expressed in words or formally taught. Using simulation and expert narrative as pedagogical strategies in the classroom setting is one way of exposing and exploring the tacit expertise inherent within district nurse first assessment visits.
District nursing first assessment visits Kennedy (2004) explored the nature of knowledge required by district nurses to carry out first assessment visits and considered the relationship of this knowledge to the subsequent decisions the district nurses made. Kennedy (2004) presented a typology of district nursing knowledge that included six dimensions of ‘knowing’, with ‘each
© 2014 MA Healthcare Ltd
C
hanges in UK age demographics and alterations in the way that health care is delivered mean that one in four people over the age of 75 will now require nursing care at home (Queen’s Nursing Institute (QNI), 2011). As a result, pre-registration adult nurse education is increasingly preparing student nurses for a future career within the community (QNI, 2013). District nurses undertake complex, multidimensional health and social assessments and care in a non-clinical setting and work in partnership with patients and their significant others to promote practical and psychological coping mechanisms and self-care.The district nurse first assessment visit is key to developing a therapeutic partnership and it is often during this visit that expertise within district nursing practice emerges (Bryans and McIntosh, 2000). The holistic, contextual and dynamic aspects of nursing in the home setting can make district nursing expertise difficult to illustrate and demonstrate within the classroom setting. This article will explore how an understanding of expertise development theory can enable the tacit expertise that occurs within the district nurse first assessment visit to be made visible to student nurses, using simulation and expert narrative as a pedagogical strategy.
Email: [email protected]
British Journal of Community Nursing December 2014 Vol 19, No 12
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 16, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION AND TRAINING dimension combining ways of knowing into coherent wholes to facilitate understanding’ (Kennedy, 2004:404): w Getting to know the patient in their own setting w Getting to know the carer w Knowing what needs to be done now w Knowing what may happen in the future w Knowing/recognising knowledge deficits w Knowing the community resources and services. Kennedy (2004) differentiates between ‘knowing that’ as theoretical knowledge and ‘knowing how’ as practical knowledge and suggests that the theoretical knowledge of experienced nurses becomes embedded into the practice context. If ‘knowing how’ is practical knowledge, as Kennedy suggests, this can potentially be explored and modelled within the classroom setting using simulation and expert narrative.
Knowing the patient: embodied understanding ‘of’ and ‘in’ practice Dall’Alba and Sandberg (2006) introduce the concept of an embodied understanding ‘of ’ and ‘in’ practice or knowing, acting and being, which they argue is overlooked in stage models such as Benner and Tanner’s (1987). They propose an alternative model of skill development that incorporates horizontal and vertical dimensions that allow for a range of development trajectories. The horizontal dimension relates to skill that accompanies experience, and the vertical dimension relates to variations in the embodied understanding ‘of ’ and ‘in’ practice. Dall’ Alba and Sandberg (2006) explain that the way in which professional practice is understood, in an embodied sense, is fundamental to how the practice in question is performed and developed. Dall’ Alba and Sandberg (2006) explore the concept of ‘unfolding circularity’ and Dewey’s notion of ‘habit’ and ‘continuity of experience’ and use these to explain how an embodied understanding of practice forms the basis for the professional skill that is being developed.
© 2014 MA Healthcare Ltd
Relevance to community nursing Research by McMurray (1992) considered the difference in practice between novice and expert nurses in community nursing. Their data identified an expert as operating with the following characteristics synchronously: w Knowledge w Empathy w Appropriate communication w Holistic understanding w Ability to get right to the problem at hand w Self-confidence in perceptions, judgments and intervention strategies. These characteristics mirror the expert practice inherent within Benner and Tanner’s (1984) expert stage and Kennedy’s (2004) typology of knowledge. The patient assessment process is seen by Kennedy (2004) as an inherently social process, with nurses getting to know the patient and the carer in their own setting in order to understand how the patient is responding to their particular clinical situation. This is supported by Benner
and Tanner (1987:28), who argue that the
‘expert nurse needs an in-depth knowledge of the patient in order to operate with a well developed sense of salience’.
How to teach expertise: simulation and expert narrative Although context-free knowledge and skills have traditionally been acquired in formal professional education, consideration is now being given to instructional conditions that explore the prospective development of expertise (Bransford and Schwartz, 2009). Dall’Alba and Sandberg (2006: 38) mention Benner’s work, emphasising that
‘professional development is not only accumulating knowledge and skills, but learning to deal with situations encountered in qualitatively different and more complex ways’. Bransford and Schwartz (2009:441) suggest that it is
‘valuable to let students experience performance conditions or the complexities of a situation and then provide and demonstrate information about an expert performance, as this helps them to understand these techniques in relation to their own success and failures’. The description by Bransford and Schwartz (2009) reflects the simulated first assessment visit session that firstyear adult nursing students take part in. The session aimed to enable students to gain insight into the principles of holistic nursing care in the home setting prior to undertaking their community practice placements in the second year. The learning outcomes for the session included the students gaining an understanding of how the therapeutic nurse–patient relationship supports decision making and the optimisation of patient wellbeing and independence (Doherty and Thompson, 2014). Students were also supported to use critical thinking skills to apply the nursing process to prioritise and co-ordinate care planning and to recognise and proactively manage risk during a home visit.
Simulation A simulation room was created to replicate the ambience of a patient’s living room and a typically complex first assessment visit scenario was developed.The simulation was built around the environmental fidelity of the simulation room, rather than any interaction or role play with actors. The students were given a district nurse referral letter from a GP asking them to visit a patient to assess a wound on the patient’s leg, to measure blood pressure and to undertake urinalysis and some routine blood tests. Background information was also provided, including the patient’s past medical history (type 2 diabetes, osteoporosis), medication and the observation that the patient has recently been widowed and her neighbours are concerned about how she is coping. When the students enter the ‘living room’, the curtains are drawn and the radio is on. A mannequin is sitting on the settee, with a wound dressing on ‘her’ leg and a cat on ‘her’ lap. The mannequin is sitting on an incontinence pad and there is a commode next to the sofa. There is a tin of
British Journal of Community Nursing December 2014 Vol 19, No 12
609
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 16, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION AND TRAINING
‘skilled performance involves intuitive assessment of each situation against a background of previous experience … or skilful know-how.’ The use of concept maps help the students to visualise the connections between the actual and potential problems identified—for example, how pain can affect mobility, which could then cause incontinence and subsequent pressure ulcer development, leading to depression and isolation, which then affects wellbeing.
Student responses and tools for analysis Initially, the students, acting within the realms of Benner’s (1984) ‘novice’ stage, plan care under the protection of rules and assessment tools. Gatley (1992) proposes that the subsequent development of flexibility when moving naturally through the stages of proficiency can be arrested by an overreliance on assessment ‘tools’. It is arguably the case that there are often no generalisable rules in district nurse first assessment visits, since each situation is subtly unique and unfolds differently. In complex social and health-care scenarios in the home setting, assessment tools or checklists could be seen as a barrier to expert practice. A novice practitioner can falter in a complex situation by trying to fit many intangible problems into an assessment tool and can feel overwhelmed by the issues identified. Within this simulation scenario a number of assessment tools could have been used, such as wound assessment, pressure ulcer risk assessment, depression and nutrition screening tools. However, the ‘expert’ nurse often does not base decision making on these tools, rooted as they are in Benner’s (1984) novice/advanced beginner stages. Throughout the session, emphasis is placed on the therapeutic relationship between the nurse and the patient and the often sensitive negotiations involved in shared care planning. The ‘expert’ nurse sees the situation as a whole and uses his/her experience
610
‘of ’and ‘in’ practice and ‘intuition’ to ‘zero in on the accurate region of the problem’. As a result, the session naturally evolves into what Gatley (1992) acknowledges as a strength of Benner’s (1984) work—uncovering expertise in clinical practice.
Evaluations of simulation The first assessment visit simulation session was evaluated positively by the students. Students either ‘agreed’ or ‘strongly agreed’ that they had a better understanding of the community nurse role in the home setting and felt more confident about their forthcoming community placement. Further evaluation after the students’ community placements is also planned.
Towards intuitive expertise: implications for practice The described strategy for education towards expertise is supported by McMurray (1992), who identifies that educators should acknowledge the value of intuitive as well as analytical thinking created through simulated case studies and argues that education must be designed to stimulate perceptual as well as analytical abilities in the learner. McMurray (1992) suggests that this is achieved though educational practice that stimulates inferential and intuitive thinking in learners. Dall’Alba and Sandberg (2006) explain how education can promote the development of understanding ‘of ’ and ‘in’ practice, creating opportunities that call into question and extend students’ understanding of practice. This is supported by Bransford and Schwartz (2009), who differentiate between ‘learning expertise and teaching expertise’, with learning expertise involving proactive learners engaging in what Ericsson (1993) termed ‘deliberate practice’. Bransford and Schwartz (2009) argue that, within deliberate practice, students practise on problems that stretch them rather than doing what they can already do again. Gatley (1992) argues that active enquiry, which is fostered by inductive teaching, is required to move beyond Benner’s (1984) ‘competence’ stage. Community nursing education should aim to engage the learner in context-driven, classroom-based scenarios in order to model expert practice and enable intuitive, adaptive and flexible practitioners who are responsive to the complex and everchanging community practice environment to develop. Community nurses working with pre-registration students during their community placements could also aim to use the principles of the simulation session. This makes visible to students the expertise inherent within their role and supports students to reflect on and explore the complexities of the situations they experience in practice.
Conclusion This article has examined how theoretical models of expertise can be used to place district nursing expertise into the pedagogic structure of nurse education. The range and nature of district nursing knowledge involved in the first assessment visit and the cognitive and affective aspects inherent within district nursing practice have been
© 2014 MA Healthcare Ltd
biscuits, an ashtray with cigarette ends and a tin box full of analgesics and laxatives within the patient’s reach on a side table. A stack of unpaid bills and a walking stick are next to the sofa and a walking frame is placed in a corner of the room.The mannequin has slippers dangling off her feet and there is a stack of old newspapers piled around the sofa. A pillow and blanket are hidden behind the sofa. The students enter the simulation room in small groups and work together looking for clues in the room. It is suggested that they use these, along with the information they have in the referral letter, to identify actual and potential problems. They do not undertake the practical tasks requested by the GP in this session. After their immersion in the patient’s ‘living room’, the students come together as a group with the facilitator where actual and potential problems are elucidated and discussed. The students have the opportunity to visualise decision making and care planning through the lens of a subject expert—making visible the ‘knowing that’ and also the ‘knowing how’, using the facilitator’s experience as a district nurse. This attempts to demonstrate the concept of intuition as explored by Dall’Alba and Sandberg (2006), who identify that
British Journal of Community Nursing December 2014 Vol 19, No 12
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 16, 2015. For personal use only. No other uses without permission. . All rights re
EDUCATION AND TRAINING considered (Bryans and McIntosh, 2000). By using contextbound simulated or real district nurse scenarios along with expert narrative, the concept of expertise can be made visible to learners, both within the education setting and in practice. Furthermore, an understanding of the importance of knowing individual patients, using an embodied understanding ‘of ’ and ‘in’ practice (Dall’ Alba and Sandberg, 2006) and ‘knowing how’ (Dreyfus and Dreyfus, 1987) can be developed. BJCN Accepted for publication 14 November 2014
Ericsson KA, Krampe RT,Tesch-Römer C (1993) The role of deliberate practice in the acquisition of expert performance. Psych Rev 100(3): 363–406 Gardner L (2013) Benner, reflections and experiences: some further thoughts. Nurse Educ Today 33(3): 183–4 Gatley E (1992) From novice to expert: the use of intuitive knowledge as a basis for district nurse education. Nurse Educ Today 12(2): 81–7 Kennedy C (2004) A typology of knowledge for district nursing assessment practice. J Adv Nurs 45(4): 401–9 McMurray A (1992) Expertise in community health nursing. J Community Health Nurs 9(2): 65–75 Queen’s Nursing Institute (2011) Nursing People at Home:The Issues, the Stories, the Actions. http://tinyurl.com/ldg5lwe (accessed 14 November 2014) Queen’s Nursing Institute (2013) Transition to Community Nursing Practice. http://
Benner P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park, CA Benner P, Tanner C (1987) Clinical judgment: how expert nurses use intuition. Am J Nurs 87(1): 23–34 Bransford J, Schwartz D (2009) It takes expertise to make expertise: some thoughts about why and how and reflections on the themes. In: Ericsson AK (ed), Development of Professional Expertise: Toward Measurement of Expert Performance and Design of Optimal Learning Environments. Cambridge University Press, Cambridge: 432–48 Bryans A, McIntosh J (2000) The use of simulation and post-simulation interview to examine the knowledge involved in community nursing assessment practice. J Adv Nurs 31(5): 1244–51 Dall’Alba G, Sandberg J (2006) Unveiling professional development: a critical review of stage models. Rev Educ Res 76(3): 383–412 Doherty M, Thompson H (2014) Enhancing person-centred care through the development of a therapeutic relationship. Br J Community Nurs 19(10): 503–7 Dreyfus H, Dreyfus S (1986) Mind over Machine:The Power of Human Intuition and Expertise in the Era of a Computer. Free Press, New York NY English I (1993) Intuition as a function of the expert nurse: a critique of Benner’s novice to expert model. J Adv Nurs 18: 387–93
tinyurl.com/muauhpk (accessed 14 November 2014)
KEY POINTS
w It is useful to use simulation and expert narrative as pedagogical strategies to explore tacit expertise in the district nurse’s first assessment visit
w It is important for learners to practise on complex problems, rather than repeating what they already know
w There is significant value in intuitive as well as analytical thinking, i.e. knowing the patient and having an embodied understanding ‘of’ and ‘in’ practice
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